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Requirements:

  1. What is your primary (one) diagnosis for this patient at this time? (support the decision for your diagnosis with pertinent positives and negatives from the case)
  2. Identify the corresponding ICD-10 code.
  3. Provide a treatment plan for this patient’s primary diagnosis which includes:
    • Medication*
    • Any additional testing necessary for this particular diagnosis*
    • Patient education
    • Referral
  4. Provide an active problem list for this patient based on the information given in the case.
  5. Are there any changes that you would also make to this patient’s overall treatment plan at this time? Must provide an EBM argument for each treatment or testing decision.
  6. Provide an appropriate F/U plan. 

*If part of the plan does not warrant an action, you must explain why. ALL medication and testing decisions (or decisions not to treat with medication or additional testing) MUST be supported with an evidence-based medicine (EBM) argument. Over-the-counter (OTC) and RXs must be written in full as if handing a script to the patient in the office. 

Case Study

Now, assume that you sent your patient for labs and she returns the following day, as instructed, to review the results.

CBC with differential

WBC 8.6 x10E3/uL
RBC 4.44 x 10E6/uL
Hemoglobin 14.0 g/dL
Hematocrit 41.2%
MCV 93fL
MCH 31.5 pg
MCHC 34.0 g/dL
RDW 13%
Platelet 241 x 10E3/uL
Neutrophils % 67%
Lymphocytes % 22%
Monocytes % 8%
Eosinophils % 3%
Basophils % 0%
Absolute Neutrophils 5.7 x 10E3/uL
Absolute Lymphocytes 1.9 x 10E3/uL
Absolute Monocytes 0.7 x 10E3/uL
Eosinophils Absolute 0.3  x 10E3/uL
Basophile Absolute 0.0  x 10E3/uL
Immature Grans % 0%
Absolute Immature Grans 0.0 x 10E3/uL

You can also check out (Solution) NR511 Week 6: Clinical Case Study Part One Discussion.

Solution

  1. What is your primary (one) diagnosis for this patient at this time? (support the decision for your diagnosis with pertinent positives and negatives from the case)

The primary diagnosis I chose for this patient is Hypothyroidism. Pertinent positives to support this diagnosis include patient self-reports of cold intolerance, generalized weakness, feeling as if she cannot get out of bed, weight gain, and now with the most recent laboratory testing elevated TSH (6.770 uIU/mL). Clinical (overt) hypothyroidism is diagnosed on the basis of characteristic clinical features (e.g., mental slowing, depression, dementia, weight gain, constipation, dry skin, hair loss, cold intolerance, hoarse voice, irregular menstruation, infertility, muscle stiffness and pain, bradycardia, hypercholesterolemia), a serum TSH above the reference range, and T4 (and/or triiodothyronine [T3]) below the reference range (Nygaard, 2018)….Kindly click the purchase icon to purchase the full solution at $10